Demand for Cancer Screening Services: Results From Randomized Controlled Discrete Choice Experiments.

OBJECTIVES: Low uptake of cancer screening services is a global concern. Our aim was to understand factors that influence the screening decision, including screening and treatment subsidies and a gain-frame message designed to present screening as a win-win. METHODS: We analyzed preferences for mammography and Pap smear among women in Singapore by means of discrete choice experiments while randomly exposing half of respondents to a gain-framed public health message promoting the benefits of screening. RESULTS: Results showed that the message did not influence stated uptake, and given the levels shown, respondents were influenced more by treatment attributes, including effectiveness and out-of-pocket cost should they test positive, than by screening attributes, including the offer of a monetary incentive for screening. Respondents also underestimated the survival chances of screen-detected breast and cervical cancers. CONCLUSIONS: Combined, these findings suggest that correcting misconceptions about screen-detected cancer prognosis or providing greater financial protection for those who test positive could be more effective and more cost-effective than subsidizing screening directly in increasing screening uptakes.

Measuring Socioeconomic Inequality in Obesity: Looking Beyond the Obesity Threshold.

We combine two of the most widely used measures in the inequality and poverty literature, the concentration index and Foster-Greer-Thorbecke metric to the analysis of socioeconomic inequality in obesity. This enables us to describe socioeconomic inequality not only in obesity status but also in its depth and severity. We apply our method to 1971-2012 US data and show that while the socioeconomic inequality in obesity status has now almost disappeared, this is not the case when depth and severity of obesity are considered. Such socioeconomic gradient is found to be greatest among non-Hispanic whites, but decomposition analysis also reveals an inverse relationship between income and obesity outcomes among Mexican Americans once the effect of immigrant status has been accounted for. The socioeconomic gradient is also greater among women with marital status further increasing it for severity of obesity while the opposite is true among men. Overall, the socioeconomic gradient exists as poorer individuals lie further away from the obesity threshold. Our study stresses the need for policies that jointly consider obesity and income to support those who suffer from the double burden of poverty and obesity-related health conditions. © 2016 The Authors. Health Economics Published by John Wiley & Sons Ltd.

Measuring High-Risk Patients' Preferences for Pharmacogenetic Testing to Reduce Severe Adverse Drug Reaction: A Discrete Choice Experiment.

OBJECTIVES: To investigate patient preferences and willingness to pay (WTP) for a genetic test that can reduce the risk of life-threatening adverse drug reactions (ADRs). We hypothesize that test features (risk of developing the adverse reaction with and without testing, test cost, and treatment cost) and the choice context (physician recommendation and the most common choice made by peer patients) will influence choices. METHODS: A discrete choice experiment was conducted in which 189 patients at high risk for gout were asked to choose between treatment options that varied along key attributes. A latent class logit model was used to analyze the choice data and test the hypotheses. RESULTS: We identified two classes of patients: the risk-averse class and the cost-conscious class. The WTP to reduce the risk of life-threatening ADRs from 1 out of 600 to 1 out of 1 million was SGD1215 in the risk-averse class. In contrast, in the cost-conscious class, the WTP was insensitive to the extent of risk reduction. Overall, the predicted take-up rate for the test is 65% at a price of SGD400. If the test was recommended by a physician or was chosen by most of the patients, the take-up rate for the test would increase by 8.5 and 1.5 percentage points, respectively. CONCLUSIONS: There is a potentially large demand for genetic tests that could reduce the risk of life-threatening ADRs. Physician recommendations and providing information on the choices of others are powerful influences on demand, even more so than moderate price reductions.

Measuring overfitting in nonlinear models: a new method and an application to health expenditures.

When fitting an econometric model, it is well known that we pick up part of the idiosyncratic characteristics of the data along with the systematic relationship between dependent and explanatory variables. This phenomenon is known as overfitting and generally occurs when a model is excessively complex relative to the amount of data available. Overfitting is a major threat to regression analysis in terms of both inference and prediction. We start by showing that the Copas measure becomes confounded by shrinkage or expansion arising from in-sample bias when applied to the untransformed scale of nonlinear models, which is typically the scale of interest when assessing behaviors or analyzing policies. We then propose a new measure of overfitting that is both expressed on the scale of interest and immune to this problem. We also show how to measure the respective contributions of in-sample bias and overfitting to the overall predictive bias when applying an estimated model to new data. We finally illustrate the properties of our new measure through both a simulation study and a real-data illustration based on inpatient healthcare expenditure data, which shows that the distinctions can be important.

Comparison of preferences for end-of-life care among patients with advanced cancer and their caregivers: A discrete choice experiment.

BACKGROUND: Patients with advanced cancer often have to make difficult decisions, such as how much to spend on moderately life-extending treatments. This and other end-of-life decisions are also influenced by their informal caregivers. Understanding the relative value that patients and their caregivers place on various aspects of end-of-life care can help clinicians tailor treatments to best meet the preferences of their patients. AIM: To quantify willingness to pay of patients with advanced cancer and their caregivers to extend the patients' life by 1 year and to compare this result to their willingness to pay for other end-of-life improvements. DESIGN: Cross-sectional survey using a discrete choice experiment. PARTICIPANTS: A total of 211 patients with stage IV cancer and their informal caregivers. RESULTS: The willingness to pay of patients to extend their life by 1 year (S$18,570; 95% confidence interval: S$6687-S$30,542) was not statistically different from their willingness to pay to avoid severe pain (S$22,199; S$11,648-S$32,450), to die at home (S$31,256; S$21,249-S$41,391), not be a burden on family and friends (S$4051; -S$3543 to S$11,568), or to receive a high-quality health-care experience (S$16,191; S$9266-S$23,037). Consistent with our hypothesis, caregivers had a greater willingness to pay than patients to extend life (S$61,368; S$37,030-S$86,210) and for most other end-of-life improvements. CONCLUSION: Results highlight the importance of pain management, supporting home deaths, and addressing other end-of-life concerns, in addition to efforts to extend life. Differences in willingness to pay of patients and caregivers suggest the need for eliciting patient preferences during treatment decision making as opposed to relying on caregiver input.

International Comparison of Poststroke Resource Use: A Longitudinal Analysis in Europe.

BACKGROUND: Long-term costs often represent a large proportion of the total costs induced by stroke, but data on long-term poststroke resource use are sparse, especially regarding the trajectory of costs by severity. We used a multinational longitudinal survey to estimate patterns of poststroke resource use by degree of functional disability and to compare resource use between regions. METHODS: The Survey of Health, Ageing and Retirement in Europe (SHARE) is a multinational database of adults 50 years and older, which includes demographic information about respondents, age when stroke first occurred, current activity of daily living (ADL) limitations, and health care resource use in the year before interview. We modeled resource use with a 2-part regression for number of hospital days, home nursing hours, and paid and unpaid home caregiving hours. RESULTS: After accounting for time since stroke, number of strokes and comorbidities, age, gender, and European regions, we found that poststroke resource use was strongly associated with ADL limitations. The duration since the stroke event was significantly associated only with inpatient care, and informal help showed significant regional heterogeneity across all ADL limitation levels. CONCLUSIONS: Poststroke physical deficits appear to be a strong driver of long-term resource utilization; treatments that decrease such deficits offer substantial potential for downline cost savings. Analyzing internationally comparable panel data, such as SHARE, provide valuable insight into long-term cost of stroke. More comprehensive international comparisons will require registries with follow-up, particularly for informal and formal home-based care.

Non-communicable diseases and injuries in Pakistan: strategic priorities.

Non-communicable diseases, including cardiovascular diseases, cancers, respiratory diseases, diabetes, and mental disorders, and injuries have become the major causes of morbidity and mortality in Pakistan. Tobacco use and hypertension are the leading attributable risk factors for deaths due to cardiovascular diseases, cancers, and respiratory diseases. Pakistan has the sixth highest number of people in the world with diabetes; every fourth adult is overweight or obese; cigarettes are cheap; antismoking and road safety laws are poorly enforced; and a mixed public-private health-care system provides suboptimum care. Furthermore, almost three decades of exposure to sociopolitical instability, economic uncertainty, violence, regional conflict, and dislocation have contributed to a high prevalence of mental health disorders. Projection models based on the Global Burden of Disease 2010 data suggest that there will be about 3·87 million premature deaths by 2025 from cardiovascular diseases, cancers, and chronic respiratory diseases in people aged 30-69 years in Pakistan, with serious economic consequences. Modelling of risk factor reductions also indicate that Pakistan could achieve at least a 20% reduction in the number of these deaths by 2025 by targeting of the major risk factors. We call for policy and legislative changes, and health-system interventions to target readily preventable non-communicable diseases in Pakistan.

Effects of financial incentives on motivating physical activity among older adults: results from a discrete choice experiment.

BACKGROUND: There is extensive evidence that regular physical activity confers numerous health benefits. Despite this, high rates of physical inactivity prevail among older adults. This study aimed to ascertain if incentives could be effective in motivating physical activity through improving uptake of walking programs, either with or without an enrolment fee to cover corresponding costs. METHODS: A discrete-choice conjoint survey was fielded to a national sample of older adults in Singapore. Each respondent was given ten pairs of hypothetical walking programs and asked to choose the option they preferred. Each option varied along several dimensions, including the level and type (cash, voucher, or health savings credit) of incentive and an enrolment fee. For each option, they were asked how likely they would be to join their preferred program. A random utility model (RUM) was used to analyze the responses. RESULTS: Results suggest that a free 6-month program with a $500 cash incentive would generate enrolment rates of 58.5%; charging $50 to enroll lowers this to 55.7%. In terms of incentive type, cash payments were the most preferred incentive but not significantly different from supermarket vouchers. Both were preferred to health savings credits and sporting goods vouchers. Concerns of adverse selection were minimal because those who were inactive represented at least 72% of new participants for any offered program(s) and were the majority. CONCLUSIONS: Study results demonstrate the potential for even modest incentives to increase program uptake among inactive older adults. Moreover, although cash was the most preferred option, supermarket vouchers, which could potentially be purchased at a discount, were a close alternative. Results also suggest that an enrolment fee is a viable option to offset the costs of incentives as it has only minimal impact on participation.

Informal and formal long-term care utilization and unmet needs in Europe: examining socioeconomic disparities and the role of social policies for older adults.

The rising number of older adults with limitations in their daily activities has major implications for the demands placed on long-term care (LTC) systems across Europe. Recognizing that demand can be both constrained and encouraged by individual and country-specific factors, this study explains the uptake of home-based long-term care in 18 European countries with LTC policies and pension generosity along with individual factors such as socioeconomic status. Using data from the Survey of Health, Ageing and Retirement in Europe conducted in 2019, we apply a two-part multilevel model to assess if disparities in use of LTC are driven by disparities in needs or disparities in use of care when in need. While individual characteristics largely affect the use of care through its association with disparities in need, country-level characteristics are important for the use of care when in need. In particular, the better health of wealthier and more educated individuals makes them less likely to use any type of home-based personal care. At the country level, results show that the absence of a means-tested benefit scheme and the availability of cash-for-care benefits (as opposed to in-kind) are strongly associated with the use of formal care, whether it is mixed (with informal care) or exclusive. LTC policies are, however, shown to be insufficient to significantly reduce unmet needs for personal care. Conversely, generous pensions are significantly associated with lower unmet needs, underscoring the importance of considering the likely adverse effects of future pension reforms.

The effect of weight loss on health, productivity, and medical expenditures among overweight employees.

OBJECTIVES: To test whether overweight or obese employees who achieve clinically significant weight loss of ≥ 5% have reduced medical expenditures, absenteeism, presenteeism, and/or improved Health-Related Quality Of Life (HRQOL). METHODS: The sample analyzed combines data from full-time overweight or obese employees who took part in one of the WAY to Health weight loss studies: 1 that took place in 17 community colleges (935 employees) and another in 12 universities (933), all in North Carolina. The estimations are performed using nonlinear difference-in-difference models where groups are identified by whether the employee achieved a ≥ 5% weight loss (treated) or not (control) and the treatment variable indicates preweight and postweight loss intervention. The outcomes analyzed are the average quarterly (90 d) amount of medical claims paid by the health insurer, number of days missed at work during the past month, Stanford Presenteeism Scale SPS-6, and the EQ-5D-3L measure of HRQOL. RESULTS: We find statistical evidence supporting that ≥ 5% weight loss prevents deterioration in EQ-5D-3L scores by 0.026 points (P-value=0.03) and reduces both absenteeism by 0.258 d/mo (P-value=0.093) and the likelihood of showing low presenteeism (Stanford SPS-6 score between 7 and 9) by 2.9 percentage points (P-value=0.083). No reduction in medical expenditures was observed. CONCLUSIONS: Clinically significant weight loss among overweight or obese employees prevents short-term deterioration in HRQOL and there is some evidence that employee productivity is increased. We find no evidence of a quick return on investment from reduced medical expenditures, although this may occur over longer periods.

The challenges of measuring social cohesion in public health research: A systematic review and ecometric meta-analysis.

The relationship between social cohesion and health has been studied for decades. Yet, due to the contextual nature of this concept, measuring social cohesion remains challenging. Using a meta-analytical framework, this review's goal was to study the ecometric measurement properties of social cohesion in order to describe dissimilarities in its measurement as well as bring a new perspective on the empirical usefulness of the concept itself. To this end, we analysed if, and to what extent, contextual-level reliability and intersubjective agreement of 78 social cohesion measurements varied under different measurement conditions like measurement instrument, spatial unit, ecometric model specification, or region. We found consistent evidence for the contextual nature of social cohesion, however, most variation existed between individuals, not contexts. While contextual dependence in response behaviour was fairly insensitive to item choices, population size within chosen spatial units of social cohesion measurements mattered. Somewhat counterintuitively, using spatial units with, on average, fewer residents did not yield systematically superior ecometric properties. Instead, our results underline that precise theory about the relevant contextual units of causal relationships between social cohesion and health is vital and cannot be replaced by empirical analysis. Although adjustment for respondent's characteristics had only small effects on ecometric properties, potential pitfalls of this analytic strategy are discussed in this paper. Finally, acknowledging the sensitivity of measuring social cohesion, we derived recommendations for future studies investigating the effects of contextual-level social characteristics on health.

Process- and Outcome-Based Financial Incentives to Improve Self-Management and Glycemic Control in People with Type 2 Diabetes in Singapore: A Randomized Controlled Trial.

BACKGROUND: Sub-optimally controlled diabetes increases risks for adverse and costly complications. Self-management including glucose monitoring, medication adherence, and exercise are key for optimal glycemic control, yet, poor self-management remains common. OBJECTIVE: The main objective of the Trial to Incentivize Adherence for Diabetes (TRIAD) study was to determine the effectiveness of financial incentives in improving glycemic control among type 2 diabetes patients in Singapore, and to test whether process-based incentives tied to glucose monitoring, medication adherence, and physical activity are more effective than outcome-based incentives tied to achieving normal glucose readings. METHODS: TRIAD is a randomized, controlled, multi-center superiority trial. A total of 240 participants who had at least one recent glycated hemoglobin (HbA1c) being 8.0% or more and on oral diabetes medication were recruited from two polyclinics. They were block-randomized (blocking factor: current vs. new glucometer users) into the usual care plus (UC +) arm, process-based incentive arm, and outcome-based incentive arm in a 2:3:3 ratio. The primary outcome was the mean change in HbA1c at month 6 and was linearly regressed on binary variables indicating the intervention arms, baseline HbA1c levels, a binary variable indicating titration change, and other baseline characteristics. RESULTS: Our findings show that the combined incentive arms trended toward better HbA1c than UC + , but the difference is estimated with great uncertainty (difference - 0.31; 95% confidence interval [CI] - 0.67 to 0.06). Lending credibility to this result, the proportion of participants who reduced their HbA1c is higher in the combined incentive arms relative to UC + (0.18; 95% CI 0.04, 0.31). We found a small improvement in process- relative to outcome-based incentives, but this was again estimated with great uncertainty (difference - 0.05; 95% CI - 0.42 to 0.31). Consistent with this improvement, process-based incentives were more effective at improving weekly medication adherent days (0.64; 95% CI - 0.04 to 1.32), weekly physically active days (1.37; 95% CI 0.60-2.13), and quality of life (0.04; 95% CI 0.0-0.07) than outcome-based incentives. CONCLUSION: This study suggests that both incentive types may be part of a successful self-management strategy. Process-based incentives can improve adherence to intermediary outcomes, while outcome-based incentives focus on glycemic control and are simpler to administer.

Wireless Home Blood Pressure Monitoring System With Automatic Outcome-Based Feedback and Financial Incentives to Improve Blood Pressure in People With Hypertension: Protocol for a Randomized Controlled Trial.

BACKGROUND: Hypertension is prevalent in Singapore and is a major risk factor for cardiovascular morbidity and mortality and increased health care costs. Strategies to lower blood pressure include lifestyle modifications and home blood pressure monitoring. Nonetheless, adherence to home blood pressure monitoring remains low. This protocol details an algorithm for remote management of primary care patients with hypertension. OBJECTIVE: The objective of this study was to determine whether wireless home blood pressure monitoring with or without financial incentives is more effective at reducing systolic blood pressure than nonwireless home blood pressure monitoring (usual care). METHODS: This study was designed as a randomized controlled open-label superiority study. A sample size of 224 was required to detect differences of 10 mmHg in average systolic blood pressure. Participants were to be randomized, in the ratio of 2:3:3, into 1 of 3 parallel study arms :(1) usual care, (2) wireless home blood pressure monitoring, and (3) wireless home blood pressure monitoring with financial incentives. The primary outcome was the mean change in systolic blood pressure at month 6. The secondary outcomes were the mean reduction in diastolic blood pressure, cost of financial incentives, time taken for the intervention, adherence to home blood pressure monitoring, effectiveness of the framing of financial incentives in decreasing nonadherence to blood pressure self-monitoring and the adherence to antihypertensive medication at month 6. RESULTS: This study was approved by SingHealth Centralised Institutional Review Board and registered. Between January 24, 2018 and July 10, 2018, 42 participants (18.75% of the required sample size) were enrolled, and 33 participants completed the month 6 assessment by January 31, 2019. CONCLUSIONS: Due to unforeseen events, the study was stopped prematurely; therefore, no results are available. Depending on the blood pressure information received from the patients, the algorithm can trigger immediate blood pressure advice (eg, Accident and Emergency department visit advice for extremely high blood pressure), weekly feedback on blood pressure monitoring, medication titration, or skipping of routine follow-ups. The inclusion of financial incentives framed as health capital provides a novel idea on how to promote adherence to remote monitoring, and ultimately, improve chronic disease management. TRIAL REGISTRATION: ClinicalTrials.gov NCT03368417; https://clinicaltrials.gov/ct2/show/NCT03368417. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/27496.

Facilitators of and barriers to implementing a traditional Chinese medicine collaborative model of care for axial spondyloarthritis: a qualitative study.

BACKGROUND: Conventional therapy may be inadequate for many patients with axial spondyloarthritis (axSpA). Traditional Chinese medicine (TCM) may be a viable alternative, but its effectiveness for axSpA is unknown. We are currently conducting a pragmatic randomised controlled trial (RCT) to investigate the effectiveness of a TCM collaborative model of care (TCMCMC), which combines usual rheumatologic care with acupuncture for patients with axSpA. This nested qualitative sub-study aims to identify facilitators of and barriers to the implementation of the TCMCMC. METHODS: We conducted individual in-depth interviews with participants who had completed the acupuncture regimen to elicit opinions on the facilitators of and barriers to the implementation of the TCMCMC. The interviews were transcribed and analysed using thematic analysis. RESULTS: Twelve participants were included, with data saturation occurring after 10 interviews. The analysis revealed both a number of important 'facilitators' and 'barriers'. Facilitators to the implementation of the TCMCMC included effectiveness of TCM to relieve symptoms, inadequacy of conventional treatment and positive social perceptions of TCM. Barriers included scepticism towards TCM, inability of TCM to provide instant relief, needle-related discomfort, variable effectiveness of TCM influenced by physicians' skills and experience and the high cost of TCM. Recommendations to overcome barriers included further patient education about TCM. CONCLUSION: Policymakers should take into account the various feasibility factors identified in this study when developing and implementing a TCMCMC. TRIAL REGISTRATION NUMBER: NCT03420404 (ClinicalTrials.gov).

Effectiveness and cost-effectiveness of incentives as a tool for prevention of non-communicable diseases: A systematic review.

The rising epidemic of non-communicable diseases (NCDs) poses substantial health and economic challenges to both individuals and society. Application of incentive-based strategies based on traditional and behavioural economic theory has emerged as a potential strategy to address rising rates of NCDs. Yet, whether or not incentives truly represent a promising strategy for addressing NCDs has not been systematically addressed nor is it clear whether certain behavioural economic strategies outperform others or simply offering a cash-based incentive for meeting a goal. In this systematic review we aim to determine whether there is an evidence base for any of these strategies. Forty-eight published randomized controlled trials (70 contrasts) evaluating the effectiveness of incentive-based strategies for improvements in NCD risk-factors were reviewed. Our primary conclusion is that there is a lack of compelling evidence that incentives of any form represent a compelling NCD reduction strategy. More evidence for long-term effectiveness and cost-effectiveness is needed to justify third party funding of any incentive based strategy.

Using Adherence-Contingent Rebates on Chronic Disease Treatment Costs to Promote Medication Adherence: Results from a Randomized Controlled Trial.

BACKGROUND: Poor adherence to medications is a global public health concern with substantial health and cost implications, especially for chronic conditions. In the USA, poor adherence is estimated to cause 125,000 deaths and cost $US100 billion annually. The most successful adherence-promoting strategies that have been identified so far have moderate effect, are relatively costly, and raise availability, feasibility, and/or scalability issues. OBJECTIVE: The main objective of SIGMA (Study on Incentives for Glaucoma Medication Adherence) was to measure the effectiveness on medication adherence of a novel incentive strategy based on behavioral economics that we refer to as adherence-contingent rebates. These rebates offered patients a near-term benefit while leveraging loss aversion and regret and increasing the salience of adherence. METHODS: SIGMA is a 6-month randomized, controlled, open-label, single-center superiority trial with two parallel arms. A total of 100 non-adherent glaucoma patients from the Singapore National Eye Centre were randomized into intervention (adherence-contingent rebates) and usual care (no rebates) arms in a 1:1 ratio. The primary outcome was the mean change from baseline in percentage of adherent days at Month 6. The trial registration number is NCT02271269 and a detailed study protocol has been published elsewhere. FINDINGS: We found that participants who were offered adherence-contingent rebates were adherent to all their medications on 73.1% of the days after 6 months, which is 12.2 percentage points (p = 0.027) higher than in those not receiving the rebates after controlling for baseline differences. This better behavioral outcome was achieved by rebates averaging 8.07 Singapore dollars ($US5.94 as of 2 November 2017) per month during the intervention period. CONCLUSION: This study shows that simultaneously leveraging several insights from behavioral economics can significantly improve medication adherence rates. The relatively low cost of the rebates and significant health and cost implications of medication non-adherence suggest that this strategy has the potential to cost-effectively improve health outcomes for many conditions.

Traditional Chinese medicine (TCM) collaborative care for patients with axial spondyloarthritis (AcuSpA): protocol for a pragmatic randomized controlled trial.

BACKGROUND: Axial spondyloarthritis (AxSpA) is a chronic disease which results in fatigue, pain, and reduced quality of life (QoL). Traditional Chinese medicine (TCM), especially acupuncture, has shown promise in managing pain. Although a TCM collaborative model of care (TCMCMC) has been studied in cancer, there are no randomized controlled trials investigating TCM in AxSpA. Therefore, we will conduct a pragmatic trial to determine the clinical effectiveness, safety, and cost-effectiveness of TCMCMC for patients with AxSpA. We define TCMCMC as standard TCM history taking and physical examination, acupuncture, and TCM non-pharmacological advice and communications with rheumatologists in addition to usual rheumatologic care. The purpose of this paper is to describe the rationale for and methodology of this trial. METHODS/DESIGN: This pragmatic randomized controlled trial will recruit 160 patients who are diagnosed with AxSpA and have inadequate response to non-steroidal anti-inflammatory drugs (NSAIDs). Simple randomization to usual rheumatologic care or the intervention (TCMCMC) with a 1:1 allocation ratio will be used. Ten 30-min acupuncture sessions will be provided to patients assigned to the TCMCMC arm. All participants will continue to receive usual rheumatologic care. The primary endpoint - spinal pain - will be evaluated at week 6. Secondary endpoints include clinical, quality of life, and economic outcome measures. Patients will be followed up for up to 52 weeks, and adverse events will be documented. DISCUSSION: This trial may provide evidence regarding the clinical effectiveness, safety, and cost-effectiveness of a TCMCMC for patients with AxSpA. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03420404 . Registered on 14 February 2018.

Progressivity, horizontal inequality and reranking caused by health system financing: a decomposition analysis for Switzerland.

This paper presents an application of the Duclos et al. [Duclos, J.-Y., Jalbert, V., Araar A., 2003. Classical horizontal inequity and reranking: an integrated approach. Research on Economic Inequality 10, 65-100] decomposition to an analysis of the 1998 Swiss health system financing. We see that in addition to measuring horizontal inequality in the classical sense, this decomposition is more efficient and flexible than earlier ones. It is also pointed out that methods involving a nonparametric estimation lead to asymptotically biased vertical and horizontal effects. A procedure to estimate this bias is given. Finally, it is shown that despite a major reform, health system financing is still very regressive and social health insurance is more regressive than direct financing.